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ax tea } Please print or type.(Form designed for use on elite(12 pitch)typewriter.) Form Approved.OMB No 20503039 UNIFORM'HA2ARDOUS 1 Genetalor ID JJumber 2.Page 1 of 3.Emergency Response Phone 4 Mamfest Tracking Number WASTE MANIFESTV �� ..J 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phonea;, 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 6.Designated Facility Name and Site Address U.S.EPA ID Number, Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. .r _� x _ :.... .-.._ .._st, O Zul 2. 3.4. i h 1 f 14 Special Handling Instructions and Additional Information t 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if i am asmail quantity generator)is true. Generator's/Offeror's Printediryped Name Signature Month Day Year -+ 16.International Shipments ❑import to U.S. ❑Export from U.S. '::•-" Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.TransporterAcknowledgment of Receipt of Materials 12 Transporter 1 Printed(rylx'rf-NameSigttature S Day Year O IL y'. N Qz Transporter 2 PrintedlTyped Name A Signature Month Day Year t- 18.Discrepancy 18a.Discrepancy indication Space El Quantity ❑Type yp El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V Facility's Phone: w 18c.Signature ofAitemate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintediTyped Name Signature _....__..._.._ Month Day Year EPA Form 8700-22(Rev.13-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY